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Medical Nutrition Therapy Diet: Lactation Brittany Wrasman

1. Purpose a. Mothers who are breastfeeding may be asked to fill out a “Postnatal Nutrition

Risk Screen” as shown below. If the patient answers “yes” to any of the following

nutritional indicators, the registered dietitian must be notified. The patient’s

nutritional status is assessed using the “Breastfeeding/Lactation- Criteria to

Assign Risk” form, as seen below. A total score of 0-5 is representative of a low-

risk patient; 6-10 indicates medium risk; and a score >10 means the patient is at

high risk for nutritional deficiencies. Based on the results, a consult with a

registered dietitian may be initiated to “help the mother optimize her own

nutritional intake and nutritional status in order to ensure optimal breast milk

production (quantity and quality) for her infant’s growth and development (Eat

Right, 2014).”

2. Population a. Overview

i. Breastfeeding provides many health benefits to both the mother and infant.

While breastfeeding, it is important that the mother consumes a healthful

and balanced diet for proper milk production and to meet her nutritional

needs. Breastfeeding burns a significant amount of energy; therefore, a

mother’s energy needs are also increased.

b. Disease Process

i. During pregnancy and lactation, the breasts increase in size due to the

production of milk. The milk is produced in small clusters of cells called

alveoli where it then travels down the milk ducts to the milk sinuses. The

suckling action of the baby creates a suction that causes the milk to flow

into the baby’s mouth from the 15-20 openings present in each nipple.

Nerve stimulation caused from the infant’s suckling triggers the pituitary

gland to release the hormones prolactin and oxytocin. Prolactin causes the

alveoli to take proteins and sugars from the blood supply and turn them

into breast milk. Oxytocin is responsible for the “let-down” reflex, or the

passing of the milk down the ducts (Sutter Health CPMC, 2013). The

mother’s diet correlates directly with her breast milk production and

quality (Eat Right, 2014).

c. Biochemical and Nutrient Needs

i. Women who exclusively breastfeed require an additional 500 kcal/day for

the first 6 months and an additional 400 kcal/day for the second six

months or when using a formula as well (Eat Right, 2014). In addition to

maintaining milk production, meeting these energy needs will promote a

1-2 lb weight loss per month after the first month of feeding.

Breastfeeding mothers are not recommended to consume less than 1,800

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kcal per day (Eat Right, 2014). Nutrients particularly important while

breastfeeding include protein, calcium, iron, folate, and vitamins A and C

(Better Health Channel, 2011). Mothers who exclusively breastfeed are

recommended to consume a minimum of 65 g of protein per day during

the first six months. This is required for breast milk production in addition

to replacing the mother’s protein stores. Protein needs decrease slightly to

62 g/day after 6 months while weaning (Eat Right, 2014). During

pregnancy, the mother’s iron stores are depleted, which means they need

to be restored post-pregnancy. Some iron rich foods include red meats,

chicken, and fish; legumes; nuts and dried fruit; wholegrain bread and

cereals; and green leafy vegetables. Such foods can be consumed to help

the mother reach her 15 mg/day recommended requirements. Calcium

plays a key role in bone strength and is also a major component of breast

milk. The best food sources for a mother to consume to meet her 1,000

mg/day calcium needs include dairy products (Better Health Channel,

2011). Folate is important in the prevention of major birth defects, but also

plays a role in heart health and preventing cell changes that can lead to

cancer. Folate can be found in leafy vegetables, citrus fruits, beans, and

whole grains (Office of Women's Health, 2012). Folate requirements for a

breastfeeding mother are 500 mcg/day (Eat Right, 2014). Needs for

vitamins A and C increase during lactation to make up for the losses in

breast milk. Foods that commonly contain vitamin A include dark green

and yellow vegetables. Vitamin C is found in citrus fruits, berries,

tomatoes, and potatoes (Better Health Channel, 2011).

3. General Guidelines a. The emphasis during lactation is on educating the mother on how she can meet

her energy needs through a healthy diet while promoting a steady weight loss

back to her pre-pregnancy weight. Educational points would include: what foods

she can consume that will contribute to a healthy diet, the need for sufficient fluid

intake, and the risks of consuming excess amounts of caffeine and alcohol while

breastfeeding.

b. Nutrition Rx

i. Encourage a balanced diet to help the client meet individual requirements

and prevent overconsumption of “empty calories.” Use “MyPlate” as a

tool to educate clients on the appropriate servings needed from each food

group.

c. Adequacy of Nutrition Rx

i. Nutrients needed in increased amounts while breastfeeding include

magnesium, copper, zinc, iodine, selenium, vitamins A, K, and E, and the

B vitamins. A well-balance diet that corresponds to the recommendations

made for breastfeeding women according to MyPlate would be sufficient

to meet these nutrient needs. However, a multivitamin supplement may be

recommended to women who are of lower-economic status or are not

meeting their caloric needs (Eat Right, 2014).

d. Goals (Eat Right, 2014):

i. Optimal nutrition for infant and mother

ii. Normalize body composition gradually so the mother returns to her

ideal/pre-pregnancy weight.

iii. Support the mother to continue breastfeeding for a minimum of 1 year and

thereafter as long as mutually desired.

iv. Decrease the development of nutritional risks in the mother.

v. Promote adequate infant growth and development, including bone

mineralization.

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vi. Discourage use of foods and drinks that should be limited or avoid.

4. Education Material

a. “Tips for Breastfeeding Moms” Facts Sheet

http://www.nal.usda.gov/wicworks/Topics/BreastfeedingFactSheet.pdf

b. Sheets explaining what counts as a serving for each food group necessary for a

balanced diet. https://www.supertracker.usda.gov/foodtracker.aspx

5. Sample Menu a.

24-Hour Recall Suggestions for Improvement Suggested Meal Plan

Breakfast: 2 c. Coffee 4 T. Half and Half Cream 2 T. Splenda 1 Medium Banana

• Drinking a moderate amount (no more than 3 cups/day) of coffee or other caffeinated beverages does not affect your baby (USDA, 2014). However, caffeine can pass into the breast milk, so large amounts of caffeinated beverages should be avoided (Better Health Cannel, 2011).

• Switch to a lower fat or skim milk option to add to your coffee.

• Add two pieces of whole-wheat toast or 1 cup of oatmeal to your breakfast to add some whole grains into your diet and increase your caloric intake for the day.

2 oz. Grains 1 cup Fruits ½ cup Dairy

Lunch: 1 c. FF Greek Yogurt ½ c. Sliced Strawberries ¼ c. LF Granola Ham Sandwich (2 slices white bread, 2 slices deli ham, 1 slice cheddar cheese) 16 oz. Diet Pepsi

• Replace the refine white bread with two slices of whole wheat bread.

• Try switching to a low-sodium deli meat and adding some vegetables to your sandwich such as tomato and lettuce.

• Adding some raw vegetables to your lunch will also help you meet your vegetable needs for the day.

• Try switching the Diet Pepsi out for a glass of water or drink the decaffeinated form.

2 oz. Grains 1 cup Vegetables ½ cup Fruits 1 cup Dairy 2 ½ oz. Protein

Dinner: 2 oz. Baked Chicken (boneless, skinless) 2 c. Spinach (raw) 4 T. Honey Mustard Dressing 1 Large Chocolate Chip Cookie 2 Glasses Wine

• Add a glass of low fat or skim milk to dinner.

• Switch to a reduced fat dressing. • Add some brown rice or whole grain pasta

to your meal to balance your plate off with a grain source.

• Drinking alcohol is not recommended any earlier than 3 months post partum while breastfeeding. Once your child is three months old, it is recommended that you

2 oz. Grains 1 cup Vegetables 1 cup Dairy 3 ½ oz. Protein

6. Websites a. https://www.supertracker.usda.gov/foodtracker.aspx b. http://www.choosemyplate.gov/pregnancy-breastfeeding/breastfeeding-

nurtitional-needs.html

7. References a. Journal articles references

i. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108:776

ii. American Dietetic Association. Position of the American Dietetic Association: Promoting and supporting breastfeeding. J Am Diet Assoc. 2005;105(5):810-818

iii. Dewey, KG. Energy and protein requirements during lactation. Annu Rev Nutr. 1997;17:19-36.

iv. Escott-Stump S. Pregnancy and lactation. In: Nutrition and Diagnosis Related Care. Baltimore: Lippincot, Williams, and Wilkins; 2008: 7-21.

References

Academy of Nutrition and Dietetics (2013). Pocket guide for international dietetics & nutrition

terminology (IDNT) reference manual: Standardized language for the nutrition care process. Chicago, Ill: Academy of Nutrition and Dietetics.

Better Health Channel (2011). Breastfeeding and your diet. Retrieved from

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Breastfeeding_and_your_diet?ope

CDC (2013). Breastfeeding: Frequently Asked Questions (FAQs). Retrieved from

http://www.cdc.gov/breastfeeding/faq/

Dinner: 2 oz. Baked Chicken (boneless, skinless) 2 c. Spinach (raw) 4 T. Honey Mustard Dressing 1 Large Chocolate Chip Cookie 2 Glasses Wine

• Add a glass of low fat or skim milk to dinner.

• Switch to a reduced fat dressing. • Add some brown rice or whole grain pasta

to your meal to balance your plate off with a grain source.

• Drinking alcohol is not recommended any earlier than 3 months post partum while breastfeeding. Once your child is three months old, it is recommended that you wait at least four hours after having a single alcoholic drink before breastfeeding. Or you can breast pump before having a drink and use it to feed your child later (USDA, 2014).

2 oz. Grains 1 cup Vegetables 1 cup Dairy 3 ½ oz. Protein

Snacks: None

• Eating small frequent meals or adding snacks throughout the day will help contribute to a balanced diet and help keep you full and nourished.

• Healthy snack options may include: 1 cup cottage cheese and 1 cup baby carrots; 3 cups popcorn and 16 grapes.

Afternoon Snack: 1 cup Vegetable ½ cup Dairy Evening Snack: 1 oz. Grain ½ cup Fruit

Fluids:

• Staying hydrated while breastfeeding is very important. Each time you nurse the baby, drink a glass of water, with the goal of consuming 8-12 cups a day.

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Eat Right (2014). Breastfeeding/lactation- Nutrition Care Manual. Retrieved from http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=144973&ncm_heading=Nutrition%20Care

Mayo Clinic (2014). Pregnancy weight gain: What's healthy? Retrieved from

http://www.mayoclinic.org/healthy-living/pregnancy-week-by-week/in-depth/pregnancy-weight-gain/art-20044360

Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy and

pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning. Office of Women's Health (2012). Folic acid fact sheet. Retrieved from

http://womenshealth.gov/publications/our-publications/fact-sheet/folic-acid.html Sutter Health CPMC (2013). How milk is produced- Women & Infants Center. Retrieved from

http://www.cpmc.org/services/pregnancy/information/breastfeeding-milkproduction.html USDA (2014). Nutritional Needs while Breastfeeding. Retrieved from

http://www.choosemyplate.gov/pregnancy-breastfeeding/breastfeeding-nurtitional-needs.html

USDA (2014). SuperTracker. Retrieved from

https://www.supertracker.usda.gov/foodtracker.aspx USDA (2013). Tips for Breastfeeding Moms. Retrieved from

http://www.nal.usda.gov/wicworks/Topics/BreastfeedingFactSheet.pdf